Unequal access to cancer care can no longer be tolerated

September 26, 2011

Cancer is one of the leading causes of death and morbidity worldwide, and its economic burden grows year by year. In 2008, the worldwide cost of cancer due to premature death and disability, excluding direct medical costs, was estimated to be US$895 billion.

An expert report from The Lancet Oncology Commission (Lancet Oncol 2011; 12: 933-80.), a group of some of the world's leading cancer specialists, from patient advocates to economists and healthcare professionals, published today (Monday 26 September), tries to tackle the difficult problem of how to deliver affordable high quality and equitable cancer care in developed countries. Presenting the report to the 2011 European Multidisciplinary Cancer Congress [2], Professor Richard Sullivan from the King's Health Partners Integrated Cancer Centre (a collaboration between King's College London and its partner NHS Foundation Trusts  Guy's and St Thomas' and King's College Hospital, London, UK) said that ageing populations and the increasing complexity and cost of new cancer treatments meant that this issue needed urgent solutions.

"The Economist Intelligence Unit estimates the costs associated with new cancer cases alone in 2009 to be at least $286 billion. Medical costs make up more than half the economic burden, and productivity losses account for nearly a quarter. By 2030, there will be an estimated 22 million new patients with cancer per year worldwide," he said. "The global challenge to countries is how to deliver reasonably priced cancer care to all citizens  i.e. make cancer care affordable to individuals and society."

At a time when the global cancer burden is shifting to low and middle-income countries, it may seem strange to concentrate on wealthier nations, the authors say, but the unique health and disease trajectory involved in those countries through the added burden of significant acute, infectious and chronic disease necessitates a separate approach. The massive increase in expenditure on cancer care in high income countries over the last two decades is due to many factors: over-utilisation (for example, tests which are useful in one setting and not in another), high-cost innovation, disincentivisation driven by reimbursement rules and defensive medical practice  more tests and treatment to counter litigation-driven culture  consumer-driven over-demand, and futile over-treatment at the end of life.

The authors identify a whole range of immediate and medium term measures that need to be introduced to reduce the current cost base of delivering cancer care and manage the future cost curves of particularly expensive interventions such as cancer medicines. Radical action is needed to simplify and integrate patient treatment pathways, new models of care with lower cost bases need to be implemented and a whole new approach to expensive interventions  from mandatory cost-effectiveness analysis, to the prohibition of off-label use and new economic models for reimbursement and incentivisation  must be driven through healthcare systems.

Educating the public, patients and policymakers about the key issues in delivering affordable cancer care is also essential, say the authors. "Making individual patients more sensitive to the costs of care is necessary for an informed public debate around this critical issue," said Professor Sullivan.

A radical shift in cancer policy is required, the report's authors say. Political tolerance of unfairness in access to affordable cancer treatment is unacceptable. The cancer community needs to take responsibility and not accept a sub-standard evidence base and an ethos of very small benefit at whatever cost; rather there should be fair prices and real value from new technologies.

"We are at a crossroads for affordable cancer care, where our choices  or refusal to make choices  will affect the lives of millions of people. Do we bury our heads in the sand, keep our fingers crossed, and hope that it turns out fine, or do we have difficult debates and make hard choices within a socially responsible, cost-effective, and sustainable framework? The consensus from all those involved is that policy makers, politicians, patients, and health care professionals need to address this issue now," Professor Sullivan said.

"We believe that value and affordable cancer care can be introduced into the cancer policy lexicon without detracting from quality, and that the management tools, evidence, and methods are available to affect this transformation across all developed countries," he concluded.

ECCO President Professor Michael Baumann said: "It is of the utmost importance that oncology professionals promote evidence-based discussion of the economics of cancer care. All health systems face budget limitations, while at the same time the cancer burden and expenditures are increasing steeply. Every cancer patient, now and in the future, must have fair access to quality cancer care and to innovation. This can only be safeguarded by transparent and evidence-based analysis and policy development. This initiative by Lancet Oncology is a very important step in this direction."

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